NUR 160 EXAM 2 HONDROS 98 QUESTIONS
AND ANSWERS GRADED A PLUS
SOLUTION GUIDE UPDATED ACTUAL TEST
PAPER
⩥ close-ended question.
Answer: What is your name?
⩥ false reassurance.
Answer: Everything will be fine
⩥ Why Assess?.
Answer: To identify changes in pt condition, to help foresee areas of
concern
⩥ RN.
Answer: who does the initial assessment?
⩥ Within 24 hours.
Answer: When should an initial assessment be done?
⩥ discharge planning.
,Answer: What should we pay attention to when a pt is post op knee
replacement and they live on 2nd floor
⩥ Steps of an assessment.
Answer: 1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
⩥ Correct, then continue.
Answer: If a concern arises during assessment (Ex: pt c/o SOB. Sit up,
apply O2 or check tubing, teach inhale through nose, exhale through
mouth)
⩥ Order of assessmet.
Answer: Subjective then Objective (helps to identify ares of focus)
⩥ Inspect airway, auscultate lungs.
Answer: If pt c/o sore throat or recent cold
⩥ Serous Drainage.
,Answer: Clear(Good or indifferent)
⩥ Sanginous Drainage.
Answer: Blood-red(a little is ok, alot is bad)
⩥ Serosanginous Drainage.
Answer: Pink-mix of blood and serous(This is ok)
⩥ Purulent Drainage.
Answer: Puss (assess for infection and notify MD)
⩥ Absent Bowel Sounds.
Answer: Auscultate 5 mins per quadrant (Silence means NOTHING) (20
minute total) assess for an obstruction and notify MD
⩥ Normal IM injection reaction.
Answer: Burning at site, itching at site, bruising
⩥ Abnormal IM injection Reaction.
Answer: vomiting, constipation, dry mouth, rash (systemic)
⩥ TB testing.
, Answer: 1. Must be read 48-72 hrs (assessed)
2. Document date, time of injection and reading, as well as result
3. Mild swelling is normal
⩥ TB result-negative.
Answer: 10mm- healthcare workers are a strict 10
⩥ TB result-positive.
Answer: red, raised (induration)
⩥ Positive TB result.
Answer: This means that the person has been exposed to TB
⩥ At risk for TB.
Answer: nursing homes, jails, homeless, certain meds, some other
countries, healthcare workers
⩥ Hyperglycemia.
Answer: hot and dry-sugar high
⩥ Hypoglycemia.
Answer: cold and clammy-needs some candy
AND ANSWERS GRADED A PLUS
SOLUTION GUIDE UPDATED ACTUAL TEST
PAPER
⩥ close-ended question.
Answer: What is your name?
⩥ false reassurance.
Answer: Everything will be fine
⩥ Why Assess?.
Answer: To identify changes in pt condition, to help foresee areas of
concern
⩥ RN.
Answer: who does the initial assessment?
⩥ Within 24 hours.
Answer: When should an initial assessment be done?
⩥ discharge planning.
,Answer: What should we pay attention to when a pt is post op knee
replacement and they live on 2nd floor
⩥ Steps of an assessment.
Answer: 1. Introduce self
2. Explain procedure
3. wash hands
4. Identify pt
5. Provide privacy
6. Inspect, auscultate, palpate
⩥ Correct, then continue.
Answer: If a concern arises during assessment (Ex: pt c/o SOB. Sit up,
apply O2 or check tubing, teach inhale through nose, exhale through
mouth)
⩥ Order of assessmet.
Answer: Subjective then Objective (helps to identify ares of focus)
⩥ Inspect airway, auscultate lungs.
Answer: If pt c/o sore throat or recent cold
⩥ Serous Drainage.
,Answer: Clear(Good or indifferent)
⩥ Sanginous Drainage.
Answer: Blood-red(a little is ok, alot is bad)
⩥ Serosanginous Drainage.
Answer: Pink-mix of blood and serous(This is ok)
⩥ Purulent Drainage.
Answer: Puss (assess for infection and notify MD)
⩥ Absent Bowel Sounds.
Answer: Auscultate 5 mins per quadrant (Silence means NOTHING) (20
minute total) assess for an obstruction and notify MD
⩥ Normal IM injection reaction.
Answer: Burning at site, itching at site, bruising
⩥ Abnormal IM injection Reaction.
Answer: vomiting, constipation, dry mouth, rash (systemic)
⩥ TB testing.
, Answer: 1. Must be read 48-72 hrs (assessed)
2. Document date, time of injection and reading, as well as result
3. Mild swelling is normal
⩥ TB result-negative.
Answer: 10mm- healthcare workers are a strict 10
⩥ TB result-positive.
Answer: red, raised (induration)
⩥ Positive TB result.
Answer: This means that the person has been exposed to TB
⩥ At risk for TB.
Answer: nursing homes, jails, homeless, certain meds, some other
countries, healthcare workers
⩥ Hyperglycemia.
Answer: hot and dry-sugar high
⩥ Hypoglycemia.
Answer: cold and clammy-needs some candy
